Publisher

UMBJMUMBJM

Journal Healthy-Mu JournalHealthy-Mu Journal Abstract

Pneumonia is a respiratory disease that often requires a holistic approach in hospitals. The psychosocial aspects of holistic care play an important role in the recovery and well-being of patients with pneumonia. However, attention to psychosocial care for pneumonia patients, especially in nursing documentation, is still limited. This study aims to describe the implementation of psychosocial nursing care documentation in a government general hospital using a secondary data analysis approach. This research is a descriptive cohort retrospective study with a sample of 179 medical records selected using a purposive sampling technique. The instrument used is a checklist sheet for the Implementation of Psychosocial Nursing Care Documentation in Pneumonia Patients. Data analysis was carried out univariately and presented in the form of a frequency distribution table. The results showed that the completeness of nursing care documentation was 97.20% incomplete and 2.80% complete. These findings indicate that the implementation of psychosocial nursing care documentation in pneumonia patients has not been carried out completely. However, the assessment and recording of patient identity by nurses has been done well. Therefore, efforts to improve the implementation of psychosocial nursing care and documentation need to be made to improve holistic services for patients, especially those with pneumonia.

Conclusion

The study revealed that the implementation of psychosocial nursing care documentation for pneumonia patients was largely incomplete, with 97.While patient identity assessments were consistently completed, other crucial components like psychosocial assessments, diagnoses, and interventions were often missing.This highlights the need for improved training, standardized documentation practices, and a greater emphasis on holistic care to enhance the quality of care for pneumonia patients.

Future Research

Further research should investigate the specific barriers nurses face in completing psychosocial documentation, such as workload constraints or lack of training, to develop targeted interventions. Additionally, studies could explore the impact of implementing standardized psychosocial assessment tools and integrating them directly into electronic health records to streamline the documentation process and improve completeness. Finally, research is needed to evaluate the effectiveness of different educational approaches – including simulation-based training and mentorship programs – in enhancing nurses confidence and competence in conducting and documenting comprehensive psychosocial assessments for pneumonia patients, ultimately contributing to improved patient outcomes and a more holistic approach to care. These investigations should consider the perspectives of both nurses and patients to ensure that interventions are practical, acceptable, and truly address the needs of those involved in pneumonia care.

References

1. Healthy-Mu Journal. healthy mu journal issn sinta fields study pharmacy nursing midwifery nutrition medicine... journal.umbjm.ac.id/index.php/healthyHealthy Mu Journal healthy mu journal issn sinta fields study pharmacy nursing midwifery nutrition medicine journal umbjm ac index php healthy
2. Implementation of Psychosocial Nursing Care Documentation For Pneumonia Patients: A Secondary Data Analysis... journal.umbjm.ac.id/index.php/healthy/article/view/1332Implementation of Psychosocial Nursing Care Documentation For Pneumonia Patients A Secondary Data Analysis journal umbjm ac index php healthy article view 1332
3. Healthy-Mu Journal. healthy mu journal issn sinta fields study pharmacy nursing midwifery nutrition medicine... doi.org/10.35747/hmjHealthy Mu Journal healthy mu journal issn sinta fields study pharmacy nursing midwifery nutrition medicine doi 10 35747 hmj

Metadata

File size	198.67 KB
Pages	9
DMCA	Report